Interventions, Training Manuals, etc. :

The Sonagachi Project was initiated in 1992 in the Sonagachi red light area of Kolkata (Calcutta) as a health education and condom promotion program targeting sex workers. Responding to barriers and needs expressed by sex workers led the program to evolve into Durbar (www.durbar.org), a multi-component community-led structural intervention (CLSI) that targets both risk behaviors and broader structural factors that marginalize sex workers and increases their vulnerability to HIV. The Sonagachi model intervenes at multiple levels through education, community organizing, advocacy, micro-credit, STI/HIV testing and treatment, anti-trafficking and other activities. These are all designed to restructure risk environments and empower sex workers to protect themselves by reducing both their marginalization in society and their vulnerability to HIV/AIDS and STDs (see Jana, Basu, Rotheram-Borus, Newman, 2004 for a review). This project, funded by the World AIDS Foundation, builds research capacity among the India team while conducting a study of HIV prevention among commercial sex workers in three communities in India.

UCLA CHIPTS & Durbar Collaborative Evaluation Trial

In 1999 the Center for Community Health began a program of collaborative research with Durbar. A quasi-experimental intervention trial was conducted in two towns in West Bengal from 2000-2001 to evaluate the Durbar/Sonagachi model CLSI’s impact on condom use, STD infection, and empowerment outcomes linked to program activities (see Jana, Basu, Rotheram-Borus, Newman, 2004 for intervention details; see Basu, Jana, Rotheram-Borus, Swendeman, et al., 2004 for study design details). Female sex workers were selected through two-stage random selection of houses and residents in two towns’ sex work neighborhoods, or red-light areas (n=110 in each). Women were recruited to participate with informed consent and interviewed four times over 16 months. Follow-up rates were high with 90% average retention and 80% completing all four assessments.

Both neighborhoods received a reproductive health clinic that provided STI diagnosis and treatment, as well as in-clinic peer education and condom promotion as standard care. The intervention town also received the Durbar/Sonagachi model CLSI led by sex worker community leaders and high-status project staff that intervened with power brokers and stakeholders (i.e., police, political leaders, landlords, madams, etc.), led community building and organizing activities, and coordinated peer-led condom promotion and STI treatment follow-up

The study examined condom use and “empowerment” outcomes either directly targeted by the model CLSI, or indirectly targeted as suggested by the underlying theory of the community empowerment approach. Overall, sex workers reporting any condom use in recent sex acts increased significantly in the intervention community (39%) compared with the control community (11%). The proportion of consistent condom users increased 25% in the intervention community compared with a 16% decrease in the control community (Basu et al., 2004).

Results for improvements in empowerment parallel those for condom use (Swendeman et al., 2009). The CLSI significantly: 1) improved knowledge of STDs, condom protection from STD and HIV, and continued STD risk despite treatment; 2) provided a frame to motivate change based on reframing sex work as valid work, increasing disclosure of profession, and instilling a hopeful future orientation reflected in desire for more education or training; 3) improved skills in sexual and workplace negotiations reflected in increased refusal, condom decision-making, and ability to change work contract, but not ability to take leave; 4) built social support by increasing social interactions outside work, social function participation, and helping other sex workers; and 5) addressed environmental barriers of economic vulnerabilities by increasing savings and alternative income, but not working in other locations, nor reduced loan taking, and did not increase voting to build social capital. This study’s results demonstrate that, compared to narrowcast clinical and prevention services alone, empowerment strategies can significantly impact a broader range of factors to reduce vulnerability to HIV/STDs.

CHIPTS Funded Mixed-Methods Pilot Research

In 2005 CHIPTS awarded a pilot grant to a group of pre- and post-doctoral trainees (Dallas Swendeman, MPH, PhD, P.I., and Co-P.I.s Toorjo Ghose, MSW, PhD., Sheba George, PhD., and Arunansu Talukdar, MD, PhD) to continue collaborative research with Durbar, specifically to explore the Social Movement and Diffusion aspects of the intervention program. The team has conducted in-depth qualitative interviews with sex workers and community leaders, program staff, and other stakeholders (see Ghose, Swendeman, George, Chowdhury, 2008).

Following the qualitative work, a comprehensive survey was developed to more thoroughly assess power broker relations, community empowerment, collective identity, community mobilization, quality of life, and family outcomes (i.e., children’s health and education) for sex worker communities. The CHIPTS funded research supported the use of the survey in two of Durbar’s original intervention communities in Kolkata (n=100 in each), completed in December 2007, to provide pilot data for future research as well as a baseline comparison for replication sites (the pilot survey is also being implemented in the Bill and Melinda Gate’s Foundation funded replication of the Durbar model in other states in India).

Another pilot survey is in development to assess non-sex worker community members’ attitudes and behaviors in relation to sex workers, the Durbar/Sonagachi intervention, and HIV/STDs, particularly around stigma, discrimination, and marginalization.

The long-term goal for ongoing collaboration will be to conduct community randomized trials implemented across Durbars 60+ sites in West Bengal to assess the impact of community-level factors and enhanced interventions (e.g.,, cognitive-behavioral skill building, leadership training and development) on multiple risk and empowerment outcomes.

American Institute of Indian Studies (AIIS) Funded Ethnographic Research

In 2007 the AIIS awarded Dr. Swendeman a Junior Fellowship Award to conduct ethnographic and participant-observation research on the social movement aspects of Durbar and the sex worker’s rights movement in India. Dr. Swendeman participated in and observed Durbar’s first “All India Conference of Entertainment Workers”. The conference had two aims targeted to both internal social movement mobilization for sex workers and external alliance building, which exemplify Durbar’s social movement strategies. First, the conference aimed to highlight the myriad aspects of sex workers’ client interactions beyond sexual intercourse, which include singing, dancing, and conversing with clients, and with strong reference to the historical context of sex work in India. Simultaneously, the conference aimed to bridge the sex worker’s rights movement to new potential and external allies of entertainment workers (i.e., singers, dancers, actors, bar girls), who had traditionally engaged in informal sex work and currently face increasing economic pressures toward sex work as the waning caste system has de-stigmatized performance activities but enables the expanding middle class to adopt performance as hobby or profession. Dr. Swendeman’s research documented strong support for the first aim; the idea that sex work is essentially entertainment and involves much more that sexual intercourse resonated strongly with sex workers. Support for the second aim was mixed; while the entertainment workers participating in the conference supported the broad idea of sex work as entertainment work and supported the sex worker’s rights movement, they were not willing to embrace the sex work undercurrents of their lived experience or to join a Durbar led social movement of entertainment workers that included sex workers. Consistent with HIV/AIDS related research findings globally, stigma remains a significant barrier to engaging at-risk populations in HIV prevention.

Geographical location:

India, West Bengal

Targeted risk group:

Sex Workers (female, transgender, male; Brothel-based & Street-based)

Intervention model:

Community-Led Structural Intervention (CLSI). The CLSI is a multi-level intervention framework that draws on community-based participatory and empowerment approaches while emphasizing the more recent focus in HIV prevention for structural interventions. The CLSI incorporates multi-level interventions that span behavioral (e.g., peer education and outreach, condom promotion, STD treatment follow up) and structural (e.g., community STD clinics, local and national advocacy, community mobilization) intervention approaches.

Local significance (How has this project impacted the immediate population?):

The project has been expanded to 60+ sties throughout Kolkata and West Bengal, India, transforming the power dynamics within sex work communities (red-light areas) to support HIV/STD prevention and treatment, and the health and well being of sex workers and their children and families.

International significance (How has this project impacted the global community?):

The project has been sited as a model program for replication for since 2000 and served as a model for (and its leadership advisors to) the recent Bill and Melinda Gates Foundation funded scale-up of HIV prevention targeting high-risk groups in India (i.e., Project Avahan) and for sex workers specifically (i.e., Project Parivartan). Durbar also has strong links with sex workers rights organizations globally.

The Press Trust of India in 1997, reported a doubling of AIDS cases every 14 months.

India is experiencing rapid and extensive spread of HIV infection (World Health Organization, 1997). The Press Trust of India in 1997, reported a doubling of AIDS cases every 14 months. Since the first reported case of HIV infection in 1986, HIV has spread to every state and union territory in the country with 25% of infections occurring in rural areas. Gender issues and poverty are cited as major issues in the spread of the disease.

A group that continues to be at high risk is female commercial sex workers. While the degree to which commercial sex is tolerated and regulated varies across societies in India, the majority of these women are young, have low socioeconomic status, and are at immediate risk for HIV infection and other sexually transmitted diseases. The most rapid and well-documented spread of HIV has occurred in Bombay and the State of Tamil Nadu. In Bombay, home to an estimated 100,000 commercial sex workers, HIV prevalence has reached the level of 50% among sex workers, 36% in STD patients, and 2.5% in women attending antenatal clinics.

A major means of transmission for the HIV in India is married and unmarried men visiting commercial sex workers. This is exhibited through the increasing spread of HIV infection throughout the general population as their customers, often truck drivers and migrant workers, act as vectors for carrying infections back to their wives and lovers in villages all over the country. Slowing the rate of infection among sex workers and their customers is essential to protecting the spread of infection both to the general population and among these high-risk groups.

In order to meaningfully impact the spread of the epidemic, there is: 1) a need for substantial increase in the national, state, and local capacity of the Indian professional social science and biomedical community in HIV prevention program development and research evaluation; and 2) identification and demonstration of model HIV prevention programs that can be disseminated nationally and internationally.